Carriers Q&A - EDI - BeWell Carriers

With regards to recon the current process with NFP is a daily recon process and GetInsured utilizes and RCNI like approach is there an expectation we would have to have a dual process sending daily reconciliation files to NFP and monthly RCNI to GetInsured?

Issuers will begin sending monthly RCNI files for PY 2026 to GetInsured in December of 2025. Issuers will maintain the current recon process with NFP through Q1 2026.

Will all members that are migrated going to be effectuated in the GetInsured system or are effectuation files required?

All members who are auto-renewed will be auto-effectuated during the auto-renewal process. Issuers are not required to send effectuation files for auto-renewals.

If a member is renewed into a different issuer’s plan, binder payment would be required and issuers would be required to send an effectuation for these enrollments.

What is the impact to the 820 file process with this migration? While it’s obvious that we would receive the premium payment since that would move to paying the carriers directly but that is only 1 of the many we receive. What about format, timing, naming conventions, companion guide etc.

For Plan Year 2026 coverage and beyond, 820 files for APTC payments will only be sent to issuers from CMS following the standard monthly.

What about the 820 files that NFP would send for state subsidy payments? Who would be sending those in future state?

BeWell, Health Care Authority and GetInsured are reviewing the current process for the state subsidies. We expect changes and will provide more information as those changes are finalized.

Currently, BeWell reports monthly individual membership who qualify for a MAP subsidy, to the OSI. Will BeWell continue to report this information on the monthly cadence, or will this shift to carriers? If the latter, will we be provided with information on how to complete the function?

BeWell will continue to report state subsidies monthly. We are evaluating whether the format — i.e., an 820 — will change. We will provide additional information to the carriers for consideration and feedback.

2025 Retro changes will use the old layout, but will it change to GetInsured layout after the cutoff? When is the cutoff date?

Yes, it will change to the GetInsured layout. The final date is TBD.

How will Gifted Transactions for New Mexico be handled going forward?

GetInsured does not have a gifted member indicator. These members will be sent to the carrier as a passive renewal. We will notify you if you are receiving passive renewals from another carrier.

Is there an ETA for when a document showing RCNI changes will be available for review?

We will not be providing a document showing RCNI changes. We provided the sample RCNI file on 2/10 via email.

Will the Sender ID (ISA06) on the GetInsured 834 be different from the BeWell Sender ID Value?

The Sender ID will be NM0 (NM+ numerical zero).

Will GetInsured be sending Disabled Dependent as 'Ward', relationship code 15?

The dependent relationship code will be what the enrollee selects on the application. It can be Ward if they select that, but it will not always be Ward.

As rating area effective date will only be sent on maintenance transactions, can we assume it is equal to the 348 date on add transactions?

Yes, carriers should use the 348 date as the policy’s effective date.

Can the DTP349 be sent only on term and cancel transactions?

Yes, the DTP349 will only be sent on term/cancel transactions, as well as any change transactions generated after a future dated term is processed.

GetInsured will be sending INS04 as 022 / INS03 as 021 - This is normally sent for plan changes. On Companion guide, it shows this would come in for an add transaction. Would plan changes be sent with a term and add pair transaction?

Yes, plan changes will be sent as a term/add pair. The INS03 will be 021 for the add. The INS04 will be dependent on the event that generated the plan change.

For Eligibility Start date change, will Issuers get 001*29? Also, will there be a specific additional maintenance reason value associated with it? Lastly, since 356 will not be sent, which date do we use as the new Eligibility Start Date - 303 date?

Coverage effective date changes are generated by the Admin. BeWell provided carriers with an EDI Processing Guide that provided carriers with options for how to receive an effective date change file. Carriers can either receive (1) Change file (001) with new effective date or (2) Cancel/Add pair with new effective. Carriers should use the 348 date to determine the policy’s effective. The INS04 value may vary on the change file.

When the decision is made on which route NM is going with the 820 file, when will a guide be provided?

BeWell will not be issuing 820 files. The state subsidies will be provided on new State Subsidy reports.

After the Auto Renewals are sent from GetInsured to the Carriers, will BeWell send updated data to GetInsured for: (late) 2025 SEPs? Terminations for Non-pay? Update transactions which alter a member's 2025 coverage?

NPP terminations for 2025 coverage will be sent to carriers from NFP through March 1, 2026. Any retroactive adjustments for 2025 after this date will be the responsibility of the issuer to invoice and/or include for NPP termination.

SEPs after renewals will be processed in a catch-up batch renewal file. The catch-up files will include updated transactions/changes, as long as the initial change resulted in an 834 to the carrier.

Will BeWell be sending the 12/31/2024 Termination for the "Term/Add pair" for GetInsured's Auto Renewal transaction?

To be determined. We request comments from carriers about their preference.

Will we receive a 12/31/2025 termination transaction if a delinquent member then pays current, through December, and an "Unpend" transaction is sent? If so, will it be sent in the same file as the Unpend transaction?

Yes, the current processes will be followed through February 2026 for Unpends for 2025 coverage.

There is a new value in the Custom Monthly 2750 Loop called "MONTHLY MT SUBSIDY AMT" that will be used for the Medicaid Transition Premium Relief (MTPR) value. Consumers are eligible for this subsidy in the first month of on-Exchange coverage after they transition off Medicaid. This new Custom 2750 Loop will be used to flag that the consumer qualifies for MTPR in that specific month and to provide the carrier with the premium that the Exchange will cover. The carrier will determine the amount the consumer owes for the month by subtracting MONTHLY MT SUBSIDY AMT from the MONTHLY TOT RES AMT.

However, in the sample 834 attached, the coverage started on 20250101(348 date) and the MONTHLY MT SUBSIDY AMT is effective 20250601. Shouldn't the MONTHLY MT SUBSIDY AMT be effective 20250101?

MTPR is typically provided for the first month of coverage for a new policy. However, there are scenarios where an individual loses Medicaid coverage and joins an existing QHP policy. For example, a child loses Medicaid coverage in May, then joins the parents’ QHP policy in June. The household then receives the MTPR benefit for the June month.

In both cases, the member responsibility amount needs to be reduced by the MTPR amount for that month.

If we receive a retro transaction, and the first month is 100% covered by MTPR, does the next month need to be paid as well for effectuation?

No, carriers should auto effectuate any enrollment received with MTPR flagged.

Carriers Q&A – EDI

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